Ketoacidosis
[[Wikipedia:Ketone bodies|'Ketones']] in the urine, as detected by urine testing stix or a blood ketone testing meterBlood Ketone Testing Meter--Abbott's Precision Xtra, may indicate the beginning of diabetic ketoacidosis (DKA), a dangerous and often quickly fatal condition caused by low insulin levels combined with certain other systemic stresses. DKA can be fixed if caught quickly. Emergency Info Diabetics of all species therefore need to be checked for ketones with urine testing stix, available at any pharmacy, whenever insulin level may be too low, and any of the following signs or triggers are present: Note that the triggers and signs are somewhat interchangeable because ketoacidosis is, once begun, a set of vicious circles which will make itself worse. So dehydration, hyperglycemia, fasting, and presence of ketones are not only signs, they're also sometimes triggers. False Testing Results-Urine Ketones When to come to the vet Trace urinary ketones may or may not be an emergency, depending on the case. If a vet is unavailable, look for some of the other signs or triggers, and try to remedy any you can. Give extra water and food, by syringe if necessary. If it's nearly time for an insulin shot, give one. Continue testing and call a vet when possible. DKA cannot be treated at home. Veterinary care for DKA involves intravenous (IV) fluids to flush the animal's system of the ketones and when necessary, to replace depleted electrolytesPet Education.com-Drs. Foster & Smith-Potassium Requirements & DeficienciesPet Education.com-Drs. Foster & Smith-Sodium & Chloride Requirements & DeficienciesRxEd.org-Hypokalemia-Low Blood Potassium, such as bicarbonate; intravenous or intramuscular fast-acting insulin to bring the blood glucose levels downCritical Care Monitoring Considerations for the Diabetic Patient-Clinical Techniques in Small Animal Practice-2002Low-dose Intramuscular Insulin Therapy for Diabetic Ketoacidosis in Dogs-Journal of the American Veterinary Medical Association-1981; measured amounts of glucose or force feeding, sometimes by feeding tube, to force the metabolism back from fat-burning to glucose-burning. Dehydration becomes involved with ketoacidosis, which can mean that subcutaneous insulin injections are not properly absorbed; when this occurs, intravenous treatment with soluble, short-acting insulin is neededAmerican College of Emergency Physicians-Pediatric Endocrine Emergency Answer Sheet,along with rehydrating intravenous fluidsMerck Veterinary Manual-Diabetes Mellitus-Ketoacidosis. Veterinary care for DKA may involve a hospital stay of five days or more and cost, in the U.S., $2,000 or more. Some animals are DKA prone, and may have multiple episodes of the condition. Veterinarians have sometimes been known to send pets home from a DKA episode while still displaying ketones in the urine due to owner financial constraints -- this can turn into a fatal mistake. Your chances of fixing the problem yourself are slim. If your cat or dog comes back from the hospital and still has ketones showing on urine testing stix, it's usually best to find the financial means to go right back to the vet's as your pet may need to stay in hospital longer. How it happens Our bodies normally are "fueled" by burning glucose; they are able to do this provided they have enough insulin (normally or by injection). When there's not enough insulin to allow the body to burn glucose for energy, it begins metabolizing fat to fuel its cells. In particular, the brain cannot go without energy even for a second, so it demands fat conversion to ketones when glucose energy is unavailableEnergy Metabolism Explained. Continuing this process using fat and ketones instead of glucose without sufficient insulin intervention is the path to ketoacidosis. Adapted from the Wikipedia: Normally, ketone bodies are produced in minuscule quantities, feeding only part of the energy needs of the heart and brain. When insulin is inadequate, fat must be turned into ketones for energy instead, and they rapidly become a major component of the brain's fuel. As a result, the bloodstream is filled with an increasing amount of glucose that it cannot use (as the body continues adding glucose to the blood with gluconeogenesis and perhaps also glycogenolysis). This extra glucose significantly increases its osmolality. At the same time, massive amounts of ketone bodies are produced, which in addition to increasing the osmolal load of the blood, are acidic. As a result, the pH of the blood begins to change. The trace element balance of the system is altered by falling bicarbonate blood levels and rising serum potassium levels. The potassium level of the body as a whole is reduced by the polyuria of ketoacidosisKetoacidosisProviding Care for Diabetic Veterinary Patients-IJPC-2000-Page 2. There can be changes in breathing (deep, sighing breaths) because the ketones themselves are acids. Any type of acidosis can affect the respiratory system. Glucose begins to spill into the urine as the proteins responsible for reclaiming it from urine reach maximum capacity. As it does so, it takes a great deal of body water with it, resulting in dehydrationWashington State University: Fluid Therapy in Diabetes Mellitus. Dehydration worsens the increased osmolality of the blood, and forces water out of cells and into the bloodstream in order to keep vital organs perfused. The vicious cycle is now set, and if untreated will lead to coma and death. How likely is it? Since diabetic dogs are considered insulin-dependent--unable to naturally provide any of their own insulin needs once diagnosed with diabetes--they are prone to ketoacidosisBetter Medicine-E-Newsletter-June 2006. About 40% of newly-diagnosed canine diabetics have some amount of ketones when they are brought to the vetBeyond Insulin Therapy: Achieving Optimal Control in Diabetic Dogs Drs. Fleeman & Rand-U-Queensland--2005. Undiagnosed diabetic cats are also likely to be ketoacidotic by the time they're brought to a vet, but not all cats are prone to ketoacidosis. It is suggested that cats who are prone to ketoacidosis may benefit from a slightly lowered protein diet, BD Diabetes-Diet & Exercise for the Diabetic Cat, but note that this is lowered from an ideal mouse diet, not from an average domestic cat-food diet! Note also that some ketone-prone cats are ketone-prone due to pancreatitis, which requires just the opposite, a lowered-fat diet. Best to stick with an ideal cat dietDr. Lisa Pierson's Cat Diet PageMaxshouse Feline Nutrition reference page unless you know for certain otherwise. Ketones occur quickly in younger animalsUrinalysis Dipstick Interpretation-University of Georgia-Ketones. Testing for ketones The usual method of testing for ketones is with urine testing stix, available at any pharmacy. When testing urine for ketones, the sample needs to be as fresh as possible. Ketones evaporate quickly, so there's a chance of getting a false negative test result if you're testing older urineUrinalysis Dipstick Interpretations-University of Georgia-Ketones. At low levels, ketones can be detected in the urine (ketonuria) before they are found in the blood (ketonemia/ketonaemia)BMJ Student Archive-Glycosuria and Ketonuria. At present there is only one device for consumers who wish to test blood instead of urine for ketones--Abbott's Precision Xtra Abbott's Precision Xtraglucometer. The meter is known by the brand name Precision/Optimum/Xceed outside of the USAbbott's Precision/Optimum/Xceed. The premise behind blood testing for ketones is the same as that for favoring glucose testing of blood over urinePoint of Care Test Identifies Diabetic Ketoacidosis at Triage-Academic Emergency Medicine-June 2006Exploring the Clinical Utility of Blood Ketone Levels in ER Department Assessment of Pediatric Patients-Emergency Medicine Journal-October 2006Ketone Testing-Peter Chase. The urine ketone measurement, like urine glucose measurement, can be hours old; testing blood for both gives current values as of testing time Value of Testing Blood for Ketones Over Testing UrineEvaluation of an Electrochemical Sensor for Measuring Blood Ketones-Diabetes Care 2000Accuracy of an Electrochemical Sensor for Measuring Capillary Blood Ketones by Fingerstick Samples During Metabolic Deterioration After Continuous Subcutaneous Insulin Infusion Interruption in Type 1 Diabetic Patient--Diabetes Care 2003Accuracy of Serum β-Hydroxybutyrate Measurements for the Diagnosis of Diabetic Ketoacidosis in 116 Dogs-Journal of Veterinary Internal Medicine 2002. Children with Diabetes Meter Which Tests Blood for Ketones advises every family with a child with diabetes should have this type of meter because of its blood ketone testing ability. The ketone test strips are about $30 for 10 individually-wrapped strips. The Precision Xtra also does blood glucose testing with standard blood glucose test strips made for use with the meter. Further Reading *Jamie and Boots' report on what DKA feels like *Wiki cases--Feline DKA *Felinediabetes.com on Ketoacidosis * The "hows and whys of ketones" from an FDMB posting *A quick summary of DKA in cats *Dr. Elizabeth Hodgkins: Ketones and Low-Carb diet *Diabetic crisis in Cats & Concurrent Disease-North American Veterinary Conference-2005 *Wiki cases--Canine DKA *Surviving diabetic Ketoacidosis-North American Veterinary Conference-2006 *Dog ear infection *Pancreatitis in dogs *Ivermectin for dogs *How long are dogs pregnant *Why do dogs eat grass *Purina dog chow coupons * [http://www.uchsc.edu/misc/diabetes/books/ud11/ud05.pdf A chapter about ketone testing from the tenth edition of Understanding Diabetes by H. Peter Chase, MD, a book about living with insulin-dependent diabetic humans] *Wikipedia:Diabetic Ketoacidosis *Treating the Complicated Diabetic Patient--Dr. David Church--WSAVA 2001 *Understanding Diabetic Ketoacidosis--WSAVA 2005 *Emergency veterinary hospitals worldwide *Metabolic Changes in Diabetic Ketoacidosis--The Genetic Landscape of Diabetes *Diabetes Now UK-Ketones Written for people but contains a lot of good information applicable to diabetes in pets also. Category:Conditions Category:Emergencies Category:Complications Category:Vicious circles Category:Terms References Category:Conditions Category:Emergencies Category:Complications Category:Vicious circles Category:Terms